Qatar Medical Journal - Current Issue

Introduction: Language impairment can present as a symptom of both psychiatric or a neurological condition, so making an accurate diagnosis is essential for appropriate management. While primary psychiatric disorders such as schizophrenia may include thought disorganization and speech abnormalities, true language dysfunction is typically associated with neurological pathology, such as stroke, neurodegenerative diseases, or traumatic brain injury. In cases where patients present with language impairment but lack a clear medical and psychiatric history, distinguishing between these possibilities becomes particularly challenging. A comprehensive assessment, including a neurological examination with potential imaging and a psychiatric evaluation, is crucial in these scenarios. This challenge is even more pronounced in populations such as lower-skilled migrant workers, where language barriers and a lack of collateral information further complicate the diagnostic process.

Case Presentation: We report on a case of a patient presenting with significant language impairment who was initially misdiagnosed with a psychotic illness. The patient exhibited speech disturbances and communication difficulties that were initially interpreted as signs of disorganized thought processes, a hallmark of psychosis. However, further evaluation, including neuroimaging, revealed significant atrophy in the bilateral anterior temporal lobes, confirming a neurological basis for the symptoms. The absence of a prior medical history and limited collateral information contributed to the initial misdiagnosis.

Conclusion: This case highlights the critical need for a thorough psychiatric and neurological workup in patients presenting with language impairment and an unclear history. Misdiagnosis can lead to inappropriate treatment and worsen patient outcomes. A careful evaluation, including neuroimaging and linguistic assessment, is essential in distinguishing between psychiatric and neurological etiologies. Moreover, addressing barriers related to language and medical history is vital to improving diagnostic accuracy, particularly in immigrant populations.

Background: Dexmedetomidine is a highly selective α2-adrenergic agonist with sedo-analgesic properties. It has been approved by the United States Food and Drug Administration (FDA) for sedation of critically ill patients, facilitation of awake procedures, and management of patient agitation. However, its use has been occasionally associated with adverse effects like bradycardia, hypotension, and asystole. The risk of these effects, particularly cardiac arrest, is increased in the elderly, patients with multiple comorbidities, and administration of higher doses of the drug (especially loading doses). However, perioperative pericardiac arrest with only low-dose dexmedetomidine infusion, in a young healthy male, has not been previously reported.

Case Presentation: We report a 33-year-old male, ASA 1 E, who underwent open reduction and internal fixation of a left ankle fracture under spinal anesthesia. He was sedated intraoperatively with intravenous dexmedetomidine, infused at 0.2 μg/kg/h, without a loading dose. Approximately 90 minutes into the procedure, he had severe bradycardia and hypotension, leading to a peri-arrest situation. He was successfully revived with intravenous atropine and ephedrine and completed the surgery uneventfully.

Conclusion: We opine that the use of dexmedetomidine as a sedative agent in patients under spinal anesthesia requires heightened caution due to the risk of major adverse cardiac events. Our case exemplifies that this risk persists even in healthy young patients, at low drug infusion rates, and even after avoiding a loading dose.

Background: Varicella zoster virus (VZV) reactivation can occur without the characteristic rash, a condition known as zoster sine herpete (ZSH). This case report highlights a rare presentation of VZV reactivation.

Case presentation: We present the case of a 40-year-old immunocompetent woman with a five-day history of headache, followed by neuropathic dermatomal pain localized to the left C2–C3 dermatomes. Cerebrospinal fluid analysis demonstrated a positive polymerase chain reaction (PCR) for VZV, confirming a diagnosis of ZSH complicated by VZV meningitis.

Discussion: The patient’s condition necessitated intravenous acyclovir therapy for 21 days. VZV meningitis can lead to severe outcomes, highlighting the importance of prompt diagnosis and timely treatment to prevent complications. The absence of a rash in ZSH necessitates heightened clinical suspicion to avoid potentially life-threatening consequences of VZV reactivation.

Conclusion: Early recognition and prompt intervention are crucial for managing ZSH and preventing severe complications such as VZV meningitis, highlighting the importance of clinical awareness of atypical presentations of VZV reactivation among healthcare providers.

Background: Dengue is the most common arthropod-borne viral illness in humans and is prevalent in tropical and subtropical regions worldwide. Nearly half of the world’s population living in these endemic areas is at risk of infection.

Case presentation: A 42-year-old Bangladeshi male, previously healthy and working as a laborer, was admitted to Hazm Mebaireek General Hospital—a Qatar government hospital serving mainly laborer populations—with a 3-day history of abdominal pain, fever, and intermittent vomiting. He had no recent history of travel to Bangladesh before this incident. Viral studies were positive for dengue virus immunoglobulin G and immunoglobulin M. Magnetic resonance imaging revealed a posterior extradural collection extending from cervical (C) 3 to dorsal (T) 7, resulting in compression of the posterior aspect of the thecal sac and causing it to appear off-center within the spinal canal. The findings suggested that the collection was most likely infective in origin. He underwent a right-sided C7 hemilaminectomy and evacuation of an epidural hematoma at Hamad General Hospital, Qatar. Postoperatively, he improved significantly. He was subsequently transferred to the Qatar Rehabilitation Institute for an active rehabilitation program and was discharged upon completion of rehabilitation.

Discussion: Dengue is prevalent in subtropical regions and South America, accounting for nearly 75% of global cases. Qatar is a non-endemic zone for dengue fever. Spinal cord epidural hematoma due to dengue fever is extremely rare, with only five cases reported to date according to our literature review. Our case will be the 22nd reported instance—and the sixth among similar series—of spontaneous spinal hemorrhage due to dengue in the literature, and the first reported from a non-endemic zone. The neurological manifestation in our case was hemiplegia. Among the five previously reported cases, two presented with quadriplegia and three with paraplegia.

Conclusion: Gulf countries are at particularly high risk among non-endemic regions due to the large number of expatriates returning from endemic areas. This case indicates that atypical presentations of dengue can also occur in non-endemic regions. We believe that early screening for tropical fevers in suspected cases can facilitate prompt diagnosis and management of dengue fever. To our knowledge, this is the first reported case of spinal hemorrhage due to dengue fever from a non-endemic zone. Moreover, our patient presented with hemiparesis, whereas the four previously reported cases manifested as either quadriplegia or paraplegia.

Background: Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening hyperinflammatory syndrome characterized by excessive immune activation. Children with Down syndrome (DS) (trisomy 21) are at increased risk of severe infections and immune dysregulation. Although viral infections are known triggers of secondary HLH, H1N1 influenza is an uncommon cause in this population.

Case presentation: We report a 1.8-month-old male infant with DS and multiple comorbidities—including gastroesophageal reflux disease (GERD), recurrent aspiration pneumonia, and seizures—who presented with fever, hypoxemia, and splenomegaly. Laboratory investigations revealed cytopenias, hyperferritinemia (>1,650 ng/mL), and hypofibrinogenemia, fulfilling five of the HLH-2004 diagnostic criteria. H1N1 influenza was confirmed as the infectious trigger. The patient was treated with standard-dose dexamethasone and etoposide, along with oseltamivir. Despite concerns about treatment-related toxicity in DS, he tolerated the regimen without hematologic or infectious complications. He achieved clinical remission with normalization of inflammatory markers and hematologic parameters. At discharge and at three-month follow-up, he remained well with no recurrence or neurological sequelae.

Discussion: This case highlights the diagnostic and therapeutic challenges of managing HLH in children with DS. The use of conventional HLH therapy, including etoposide, was effective and well-tolerated despite theoretical concerns in this population. Although central nervous system symptoms were present, they resolved with treatment. H1N1 influenza should be considered a potential viral trigger in immunocompromised children presenting with HLH-like features.

Conclusion: H1N1 influenza-induced HLH is exceptionally rare in infants with DS. The positive outcome in this case supports the safe use of standard HLH protocols in this vulnerable population and highlights the importance of early diagnosis and multidisciplinary management to optimize outcomes.

Background: Schimke immunoosseous dysplasia (SIOD) is a condition marked by spondyloepiphyseal dysplasia (SED), leading to short stature, nephropathy, and T-cell immunodeficiency.

Case presentation: A 15-year-old male was referred to the nephrology clinic with a gradual onset of lower-limb swelling. Clinical examination revealed short stature. Laboratory studies revealed renal impairment and nephrotic-range proteinuria. Kidney biopsy showed global sclerosis in 3 of 28 glomeruli, segmental sclerosis in 16 of 28 glomeruli, and 90% foot-process effacement on electron microscopy. A skeletal survey showed flattened thoracolumbar vertebral bodies, a characteristic feature of SIOD. Flow cytometry revealed a low CD4 count. Whole-exome sequencing confirmed that the proband was homozygous for the p.(R611C) variant in the SMARCAL1 gene. The patient was treated with a calcineurin inhibitor (CNI), angiotensin receptor blockers (ARBs), and prophylactic anticoagulation. Initially, he experienced improvement in serum albumin levels and proteinuria. However, his urine protein and creatinine levels subsequently increased, prompting discontinuation of CNI. The patient progressed to end-stage kidney disease (ESKD) and required hemodialysis 18 months after the initial presentation.

Discussion: This report describes a case of SIOD, a rare multisystem disorder characterized by short stature due to SED and nephrotic syndrome, distinguishing it from other hereditary nephrotic syndromes. The patient presented unusually in adolescence with nephrotic-range proteinuria and skeletal abnormalities, representing a rarely reported juvenile variant. Genetic testing revealed a novel homozygous SMARCAL1 mutation, p.(R611C), which was confirmed in his younger sibling. However, the phenotypic expression differed, reflecting the weak genotype–phenotype correlation in SIOD. Unlike many SIOD cases, our patient did not experience recurrent infections despite abnormal immune parameters, suggesting a milder immunodeficiency and making kidney transplantation with cautious immunosuppression a feasible option. Current therapeutic challenges include the lack of effective disease-specific treatments, limited success with conventional transplantation due to infection and malignancy risks, and emerging but logistically complex approaches such as combined stem-cell and kidney transplantation.

Conclusion: SIOD is a rare genetic disorder with variable presentation and outcomes. Our patient, carrying a novel SMARCAL1 mutation and presenting with juvenile-onset disease, progressed to ESKD but had only mild immune dysfunction, making kidney transplantation a potential treatment option. Early recognition is essential to avoid unnecessary treatments, guide supportive care, and enable timely referral for advanced therapies. Clinicians should consider SIOD in patients presenting with short stature and nephrotic syndrome to optimize outcomes.

Introduction:Moraxella osloensis is a rare, Gram-negative, oxidase-positive coccobacillus that is infrequently identified as a pathogen in clinical diseases. It is usually opportunistic and associated with an immunocompromised host or the presence of invasive medical devices. Central nervous system infections caused by M. osloensis are extremely uncommon, with only a few cases documented in the literature.

Case presentation: We report the case of a 49-year-old female from Cameroon with a history of diabetes mellitus and osteoarthritis who presented in Qatar with a 10-day history of headache, fever, and vomiting. Her condition progressed to confusion and persistent fever. Cerebrospinal fluid (CSF) analysis revealed purulent leukocytosis with elevated protein and glucose levels, but cultures and Gram stain were negative—findings atypical for bacterial meningitis. Empirical treatment with ceftriaxone and acyclovir was initiated. Definitive identification of M. osloensis was achieved via 16S rRNA sequencing of the CSF. The patient received two weeks of targeted ceftriaxone therapy, resulting in clinical improvement and full recovery by Day 17 of hospitalization.

Discussion: This case highlights the diagnostic challenges associated with atypical presentations of meningitis and underscores the limitations of conventional microbiological methods in detecting rare pathogens. M. osloensis may not be isolated by routine culture and is frequently misidentified. Molecular diagnostic techniques, such as 16S rRNA sequencing, play a crucial role in achieving accurate identification. Given the organism’s potential for resistance and its association with invasive infections, prompt recognition and appropriate therapy are essential.

Conclusion:M. osloensis is a rare yet potentially serious cause of bacterial meningitis, particularly in immunocompromised patients. Molecular diagnostic techniques are indispensable for confirming the pathogen in culture-negative cases. Timely diagnosis and appropriate treatment can lead to favorable outcomes, as demonstrated in this report.

Introduction: Severe animal attacks by large predators, such as lions, are rare but devastating, often resulting in life-threatening injuries. These cases require immediate surgical intervention because of the complexity and severity of the injury. This report describes the multidisciplinary management of an adolescent who sustained extensive trauma following a pet-lion attack.

Case Presentation: A 17-year-old male was brought to the emergency department by his father after a pet lion attack. He sustained severe injuries to the scalp, chest, arms, and face, along with a depressed skull fracture and pneumocephalus. He underwent emergent surgery involving dural repair with autologous temporalis fascia and cranial reconstruction using titanium mesh by the neurosurgery team, alongside extensive soft tissue debridement and layered closure by plastic surgeons. Postoperative care included broad-spectrum antibiotics, tetanus and rabies prophylaxis, and early physical therapy. The patient remained hospitalized for 5 days, during which he showed steady improvement and was discharged with preserved neurological function and well-healed surgical sites.

Discussion: Animal attacks pose unique challenges in trauma care due to the complexity of injuries, high risk of infection, and the need for extensive reconstructive procedures. This case highlights the importance of a collaborative, multidisciplinary approach for managing such injuries and achieving optimal functional and aesthetic outcomes.

Conclusion: Complex serious traumas in different locations of the body, especially craniofacial trauma. In this case, timely intervention and coordinated care resulted in a favorable outcome, with preserved neurological function and successful wound healing. This underscores the importance of rapid, comprehensive treatment and highlights the need for preventive measures to reduce the risk of such devastating injuries.

Background: Acute kidney injury requiring dialysis (AKI-D) is a severe medical condition that is common and associated with a high rate of morbidity and mortality. Identifying predictors of kidney recovery in patients with AKI-D might lead to better care and improved kidney and patient survival. This study aims to assess the long-term clinical outcomes of patients who had AKI-D during their hospitalization and remained on dialysis at discharge and identify predictors of renal recovery after discharge.

Methods: We retrospectively studied adult patients hospitalized between January 2016 and December 2022 who had AKI-D during their hospitalization and continued receiving dialysis after discharge. Patients who had less than three months of follow-up, underwent kidney transplantation, or died within three months of dialysis initiation were excluded from the study.

Results: Of the 64 patients in the study, 20 (31%) achieved renal recovery, while 44 (69%) remained dialysis dependent. The average time to renal recovery was 93 ± 61 days. Recovered AKI-D patients had significantly lower baseline and average weekly predialysis serum creatinine after discharge and significantly higher intensive care unit admission, length of hospital stay, vasopressor use, and number of dialysis sessions than non-recovered patients. Using multivariate analysis, we identified vasopressor use as the only independent predictor of renal recovery after discharge in patients with AKI-D (odds ratio, 16.244 [95% CI, 1.22–217.17]; P = 0.035).

Conclusion: Renal recovery after discharge can be seen in up to one-third of patients with AKI-D, even if they have advanced chronic kidney disease at baseline or require dialysis for more than three months. The chance of renal recovery is higher in patients who require vasopressor use during hospitalization. Thus, patients with AKI-D should be closely monitored after discharge, and guidelines on managing such patients need to be created.